HIPAA Signature – Greenwich Medical Partners

What you are looking for?

(203) 661-2596
(203) 625-8331
644 West Putnam Avenue Suite 203
Mon-Fri: 8:00 - 5:00

(203) 661-2596
(203) 625-8331
644 West Putnam Avenue Suite 203
Mon-Fri: 8:00 - 5:00

Acknowledgement of

Notifications

Name

Agreement for Psychological Services

I understand that I have read Dr. Stiritz’s Agreement for Psychological Services and I understand and agree to comply with these policies. I understand that these policies are available to me on Dr. Stiritz’s website but that I may always request a hard copy if I am unable to access them.

Today's Date

Signature

HIPAA Notice of Privacy Practices

I acknowledge that I have read the HIPAA Notice of Privacy Practices. I understand that the HIPAA Notice of Privacy Practices is available on Dr. Stiritz’s website but that I may always request a hard copy if I am unable to access it.

Today's Date

Signature

Appointment Cancellation and Payment Policy

I understand that I will be charged for appointments not cancelled more than 24 hours in advance of my scheduled appointment. I understand that payment is due at the time of service, unless Dr. Stiritz and I have agreed to an alternate billing plan.

Today's Date

Signature